1. CHAPTER 31
INPATIENT CODING

2. Selection of Inpatient Principal Diagnosis
Condition established after study (tests)
_____ responsible for patient admission
Applies to all non-outpatient settings
Acute care, short term, long-term and psychiatric hospitals
Home health agencies; Rehab facilities; Nursing homes, etc.
Chiefly
What is the difference between the primary and principal diagnosis codes? (Principal diagnosis: Sequenced first in inpatient coding. In an outpatient setting, indicate as the primary diagnosis the main reason for the visit, and sequence the primary diagnosis first.)
The principal diagnosis is determined by the circumstances of the patient admission.
The coder should list the code for the diagnosis, condition, or problem shown in the medical record to be chiefly responsible for the services provided.
Then the coder should list additional codes that describe any coexisting conditions that affect the care of the patient for that encounter.

3. Selection of Inpatient Principal Procedure
Code from ICD-10-PCS or ICD-9-CM Volume 3
Principal procedure is:
Definitive treatment rather than
Diagnostic or exploratory
Necessary to take care of a complication
If two procedures meet criteria
Report one most closely related to principal diagnosis
(Cont’d…) 3

4. Selection of Inpatient Principal Procedure
(…Cont’d)
Procedure is significant if it:
Is surgical in nature
Carries a procedural risk
Carries an anesthetic risk
Requires specialized training 4

5. Diagnosis and Services
Diagnosis and procedure MUST _______
Medical ________ must be established through documentation
No correlation = No ____________
correlate
necessity
reimbursement
What is the reason for the use of diagnosis codes? (They establish medical necessity for the documentation.)

6. Section II.A. Symptoms, Signs, and Ill-Defined Conditions
Inpatient coders do NOT code when definitive diagnosis has been established
These codes are not to be used for principal diagnosis when there is a related definitive diagnosis.

7. Section II.B. Two or More Interrelated Conditions
Two or more interrelated conditions exist
_____ could be principal diagnosis
Either sequenced ___
Unless indicated otherwise by:
Circumstances of the admission
Therapy provided
Tabular List of Alphabetic Index
Either
first
This is true for both inpatient admissions and outpatient visits.
Neither code must be listed as principle so the order does not matter.
(Cont’d…)

8. Section II.B. Example of Interrelated Conditions
(…Cont’d)
Mitral valve stenosis and coronary artery disease (two interrelated conditions)
Either can be principal diagnosis
Either sequenced first
MVS and CAD
CAD and MVS
________ intensiveness affects choice
Mitral valve stenosis is presumed by ICD-10-CM and ICD-9-CM to be of rheumatic origin
Interrelated conditions: either diagnosis can be listed as primary.
The choice of primary diagnosis usually affects the most resource-intensive procedure.
Resource

9. Section II.C. Two or More Equal Diagnoses
Either can be sequenced first
Example: Diagnosis of viral gastroenteritis and dehydration if both are treated
__ and _
_ and __
If only dehydration is aggressively treated with IV fluids and the VG is treated with oral meds, sequence dehydration first VG D D VG
When two or more diagnoses equally meet the criteria for principal diagnosis and coding guidelines, do not provide sequencing direction; any one of the diagnoses may be sequenced first.

10. Section II.D. Comparative or Contrasting Conditions
“Either/or” diagnoses
Code as confirmed in the inpatient setting
If determination CANNOT be made, either can be sequenced first
Example: Pneumonia or lung cancer can be either
_ or __
__ or _
If both aggressively treated
This is a rare occurrence.
When two or more contrasting or comparative diagnoses are documented as “either/or,” they are coded as if the diagnosis were confirmed, and the diagnoses are sequenced according to the circumstances of the admission. P LC LC P

11. Section II.E. Symptom(s) Followed by Contrasting/Comparative Diagnosis
Symptom code sequenced ___
Then other ________
Example: Patient admitted for chest pain, either gastric reflux or peptic ulcer disease (PUD)
Sequence first chest pain
Followed by gastric reflux or PUD
Rule: code first underlying condition causing the symptom
If it is necessary to code symptom to explain resources used, code also
first
diagnoses
When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first.
The physician will state the diagnosis as “symptoms due to X or Y.” This is different from the previous section, in which the physician stated the diagnosis as “X or Y” instead of listing the symptoms.

12. Section II.F. Original Treatment Plan Not Carried Out
Principal diagnosis becomes
Condition that after study was reason for admission as inpatient
Treatment does ____ have to be carried out for condition
NOT
The condition that occasioned admission to the hospital should be sequenced as the principal diagnosis, even though treatment may not have been carried out because of unforeseen circumstances.
(Cont’d…)

13. Section II.F. Example
(…Cont’d)
Patient admitted for elective surgery, develops pneumonia, surgery canceled
Code ______ for surgery first
Code “Surgical or other procedure NOT carried out because of contraindication” (Z53.0, V64.1)
Also code _________
reason
Always place the reason the patient was admitted to the hospital first, even though treatment may or may not be carried out.
If a patient was admitted for elective tonsillectomy due to chronic tonsillitis, but when the patient came in to the hospital was found to have a very high temperature, would the chronic tonsillitis be listed first or the fever? (Tonsillitis)
pneumonia

14. Section II.G. Complications of Surgery and Other Medical Care
If admission is for treatment of a complication from surgery or other medical care
Sequence complication code as principal diagnosis
If complication is classified to series
and code lacks specificity to describe complication
an additional code for the specific complication should be assigned 14

15. Section II.H. Uncertain Diagnosis
If diagnosis at time of discharge states:
“probable,” “suspected,” “likely,” “questionable,” “possible,” or “_______”
Code condition as if condition ______ until proven otherwise (inpatient facilities code this)
Physicians report a definitive diagnosis or signs/symptoms
rule out
existed
The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that corresponds most closely with the established diagnosis.
The workup, observation, or therapies will be the same whether one is treating the confirmed condition or ruling the condition out.
(Cont’d…)

16. Section II.H. “Cough and fever, probably pneumonia”
(…Cont’d)
________: Code pneumonia, do NOT code cough and fever
_________: Code cough and fever, do NOT code pneumonia
Code symptoms in outpatient setting if a definitive diagnosis is not documented
Inpatient
Outpatient
Inpatient coders can bill for probable/possible diagnoses, but outpatient coders can only bill for confirmed diagnosis.
If a patient comes into a clinic and has abdominal pain, and the diagnosis given by the physician is rule out appendicitis, could the outpatient coder code the appendicitis? (No, because they are only ruling it out; it is not a definitive diagnosis yet.)
In what setting would the patient have to be in order to code the rule out appendicitis? (The patient would have to have been admitted into the hospital.)

17. Section II.H. Uncertain Diagnosis
Two exceptions
AIDS (B20/042) should only be assigned for confirmed cases
Avian influenza (J09.X2/488.02) should only be assigned for confirmed cases 17

18. Section II.I. Admission from Observation Unit
Patient admitted to observation for medical condition which worsens or does not improve
Patient admitted to same hospital for same condition
Principal diagnosis is medical condition which led to admission
(Cont’d…) 18

19. Section II.I. Admission from Observation Unit
(…Cont’d)
Patient admitted to observation to monitor condition (complication) following outpatient surgery
Is then subsequently admitted as an inpatient to same facility
Principal diagnosis is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”
Based on Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis 19

20. Section II.J. Admission from Outpatient Surgery
Patient receives surgery in the outpatient surgery department
Is subsequently admitted for continuing inpatient care
Guidelines for assigning principal diagnosis for inpatient admission:
(Cont’d …) 20

21. Section II.J. Admission from Outpatient Surgery
(…Cont’d)
If admission is due to a complication, assign the complication as principal diagnosis
If no complication or medical condition is documented as reason for admission, assign the reason for the outpatient surgery as the principal diagnosis
If admission is for another condition unrelated to the surgery, assign code for unrelated condition as principal diagnosis 21

22. Section III. Reporting Additional Diagnoses
Definition of “other diagnoses” are additional conditions that affect patient care requiring:
Clinical evaluation or
Therapeutic treatment or
Diagnostic procedures or
Extended length of hospital stay or
Increased nursing care and/or monitoring
(Cont’d…) 22

23. Section III. Reporting Additional Diagnoses
(…Cont’d)
Guidelines when neither Alphabetic Index nor Tabular List provide direction:
Diagnosis reported in discharge summary should be coded
Resolved conditions or status-post procedures from previous admissions that do not have bearing on current stay, should not be coded
History codes if impact on current care or influences treatment 23

24. Section III.B. Abnormal Findings
Abnormal findings of laboratory, x-ray, pathologic and other diagnostic tests:
Not reported unless provider indicates their clinical significance
If findings are outside normal range and provider has ordered other tests to evaluate condition or treatment, query provider if abnormal finding should be reported 24

25. Section III.C. Uncertain Diagnosis
If diagnosis documented at time of discharge, is listed as:
“probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out” or similar uncertain wording
Code condition as if it existed
Basis is that diagnostic workup, further workup and initial therapeutic approach will correspond to the established diagnosis 25

26. ICD-10-PCS Will replace Volume 3, Procedures of ICD-9-CM, Oct 1, 2014
Four objectives guide development:
Completeness
Expandability
Multiaxial
Standardized terminology
Four major objectives guided the development of the ICD-10-PCS: completeness, expandability, multiaxial nature, and standardized terminology.
The ICD-10-PCS has a seven-character alphanumeric code structure.
Characters 2 through 7 have a standard meaning within each section but may have different meanings across sections.
If a character is not applicable to a specific procedure, the letter Z is used.
The Tabular List provides the remaining characters needed to complete the code given in the Index.

27. Conclusion CHAPTER 31
INPATIENT CODING